Patient Communication Consent and Authorization Form

Patient Information

Name: _________________________ Date of Birth: _____________ Medical Record #: ________________

Authorization for Communication

I hereby authorize [Practice Name] to communicate with me regarding my medical care, appointments, test results, and other healthcare information via the following methods:

Preferred Communication Methods (check all that apply):

• Phone Call - Primary: (__) -
• Phone Call - Alternative: (__) -
• Voice Message
• Text Message
• Email: ________________________________
• Patient Portal

Authorized Representatives

I authorize the following individuals to receive information about my medical care:

1. Name: _________________________ Relationship: _____________ Phone: (__) - Information Type: [ ] All [ ] Limited

2. Name: _________________________ Relationship: _____________ Phone: (__) - Information Type: [ ] All [ ] Limited

Communication Restrictions

Please list any specific restrictions: ________________________________

Emergency Contact

Name: _________________________ Relationship: _____________ Phone: (__) -

Acknowledgment

I understand that:

• Electronic communications may not be secure
• Critical or emergency situations require direct phone contact or 911
• This consent remains valid until revoked in writing

Signature: _________________________ Date: _____________